I was approaching the end of a long swing shift when I received a page from the holding room nurse. "Dr. Sutton, multiple providers have tried and failed to start an IV on your next patient. Could you please come try?" As I started toward the holding room, I called the anesthesia tech and requested an ultrasound.
My patient was a young man in his mid-20s. He had a history of IV drug abuse, which had played a role in him crashing his car earlier that day. While none of his injuries were life-threatening, he had sustained painful bilateral lower extremity fractures that would require operative fixation. He was lying in a hospital bed, the splints kicked free from both legs and soft restraints attached to his wrists and ankles. A small group of nurses and residents was completing preoperative paperwork and clearing the evidence of several unsuccessful attempts at IV placement. I approached the patient and introduced myself. "Hi, I'm Dr. Sutton, the supervising anesthesiologist this evening."
The patient's response was less than polite. "Oh great, now I guess you're here to stick me like a pincushion."
I remained polite but direct. "I'll try to get an IV on you with one stick, but your history of IV drug use means your veins are in bad shape. You can help me by telling me which is your best vein."
The patient nodded toward his shoulder. "Right there. Just put me to sleep right there."
I inspected the patient's shoulder, but his vein was obscured by a large tattoo. "I can't see that vein. I think our best bet is for me to use the ultrasound and put one in your arm."
"I don't need an IV, just skin pop me!" he exclaimed, scowling.
"Skin pop you?" I asked, raising an eyebrow.
His scowl deepened as he retorted, "Yeah, just get some heroin and skin pop me!"
I considered the patient as I responded, "OK, two things. First, that's not how we do things here. You get an IV because I need to be able to give you medications to keep you safe through surgery. And second, this is a hospital! We don't have heroin!"
Growing increasingly irritated, the patient looked at me as if I were crazy. "Then take these things off me!" he demanded, indicating the soft restraints that held him. "If you don't have anything for my pain, I'm gonna get up and walk out of this s**tty hospital!"
Exasperation got the better of me momentarily as I met the patient's challenge with one of my own. "Dude, you've got two broken legs! How in the world do you plan to walk out of here?!" Taking a breath, I continued in a more conciliatory tone. "Besides, I didn't say we don't have painkillers."
"Then what do you have if you don't have heroin?" the patient asked, still visibly frustrated.
"Fentanyl."
"Oh," he replied, his glare softening. "OK, that'll probably work."
Yeah, I know, I thought. Believe it or not, I'm actually a much better pharmacologist than you. Without saying a word, I focused on placing a long 18-gauge IV in his arm under ultrasound guidance. I was rewarded with dark venous blood, which I drew back into a syringe and passed to a nurse for laboratory evaluation.
Together with the rest of my anesthesia team, I completed the patient's preoperative evaluation, and we rolled down the long hallway connecting the holding room to the orthopedic trauma OR. After applying the standard monitors and preparing for induction of anesthesia, I turned to my CRNA and SRNA. "Kevin, Jill, you ready to induce?" They nodded, and Kevin applied pressure to the patient's cricoid cartilage as I gently pushed medications through his IV.
The combination of intravenous propofol and succinylcholine should cause patients to rapidly lose consciousness, then twitch as their muscles contract and relax. But this patient continued looking at us and breathing into the facemask. Oh, crap, I thought, realizing his IV must have blown. "Does your arm hurt?" I asked.
"No! My legs hurt, and I want to leave!" the patient answered angrily. He began shaking his head violently in an attempt to escape the oxygen mask Jill held to his face. His arms and legs tugged at the restraints as he struggled to free himself. "Get this off me and let me go!"
As the patient rapidly became irrational and combative, I was forced to take decisive action. Up to this point, we'd been trying to decrease the patient's risk of regurgitating and aspirating the contents of his stomach, but as his behavior became increasingly dangerous our priority shifted to protecting ourselves and him from physical injury. Without a working IV, I had to get creative. "Kevin, how much ketamine have you got?"
"A hundred milligrams."
"Stick all of it in his deltoid. Jill, switch to 7/3 nitrous/oxygen and crank the sevo!" I instructed. The combination of intramuscular and inhalational agents would render the patient unconscious, but it would do so much more slowly than the intravenous propofol I had hoped to administer.
As the anesthetic agents took hold, the patient stopped struggling and descended into pharmacologic sleep. I considered my options for IV access. "Kevin, I don't want to drop a central line in him. I'm afraid he'll rip it out and either exsanguinate or air embolize his brain."
"How about the EJ?" Kevin asked.
I nodded. "Yeah, let's go with that." Over the next few minutes, Kevin and I each attempted to place an IV in the young man's external jugular vein but met with failure. Ten minutes later, we still had no IV and an unprotected airway.
Deciding I couldn't wait any longer to secure the patient's airway, I asked Kevin to prepare succinylcholine for IM administration. "Be ready to give it, Kev, but I'm going to look first with a GlideScope without relaxation." To my surprise, I was able to visualize the patient's vocal cords very easily, and I successfully intubated him on the first attempt. The patient bucked on the endotracheal tube once it was in place, so I asked Kevin to give him intramuscular rocuronium, a muscle relaxant. Then I turned to the SRNA and instructed, "Jill, please put him on pressure support ventilation. Once the roc hits enough for him to stop triggering the vent, switch him over to volume control." Next, I turned to the orthopedic team, which had been patiently waiting as we struggled with this challenging patient. "Thanks for your patience," I said. "I still need to get IV access, then you can get started. You'll want to get an ICU bed because I'm planning to leave him intubated."
With a look of surprise, the orthopedic resident replied, "You're leaving him tubed? Why?"
I smiled wryly. "Let me put it this way: do you want to deal with this guy awake all night long?"
Surprise disappeared from the resident's face as he nodded his understanding. "Gotcha. Good plan. I'll call the trauma team and get him a bed in the unit." The attending orthopedist indicated agreement with a thumbs up, and I turned my attention back to the patient.
"Kevin, I'm gonna do it," I lamented, shaking my head.
"Central line?" he queried.
"Yeah," I sighed. "They'll just have to keep him in restraints until they're sure he won't auto-d/c it and bleed out."
Placing the central line proved as challenging as starting a peripheral IV in this patient. After a couple attempts under ultrasound guidance, I placed a triple-lumen catheter in his internal jugular vein. "OK," I said wearily but triumphantly, "you guys can start surgerizing."
I left the OR and made my way to the faculty lounge, where I sat at a computer. My watch showed two hours had passed since I met the patient in the preop holding area. I shook my head and mouthed, "Two hours..." Then I logged into the computer and began entering notes to document all that had transpired. No sooner had I signed the final note than my pager beeped. I dialed the number shown and heard Kevin's voice on the other end of the line.
"Hey Matt," he said, "I know your shift ended a while ago. Have you already signed out and left the building?"
"No," I replied, "I'm still here finishing my charting."
Kevin chuckled. "You're gonna love this. They're done."
My jaw hit the floor. It hadn't even been twenty minutes since I walked out of the operating room! "You serious?" I asked incredulously. "You're not yanking my chain?"
"Totally serious," he laughed. "They're done. I'm taking our young friend to the unit."
I hung up the phone and shook my head again. The faculty lounge was vacant except for me, the lights dimmed. "Twenty minutes," I announced to the empty room. "Two hours to get the anesthesia going, and surgery took twenty minutes."
After a moment, I smiled and stood to leave. "Well," I continued to the otherwise silent room, "I guess I don't have much room to complain the next time they take an hour to close!"
